General Surgery Residency Training

Thyroid Factor

The Natural Thyroid Diet

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According to the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee (RRC) for Surgery, a standard general surgery residency program is expected to provide the training to enable its graduates to perform endocrine surgery safely, efficiently, and with appropriate indications, preoperative preparation and postoperative care [4,5]. The majority of surgeons in the USA who perform endocrine operations rely on this level of training.

Harness et al. evaluated the operative experience of graduating general surgery residents in the USA in an attempt to characterize what baseline level of training general surgeons have obtained for thyroid, parathyroid, and adrenal surgery [5]. They found extremely varied levels of experience for all three endocrine glands, including the thyroid (Figure 11.2) [1,5]. The average number of thyroidectomies performed by graduating chief residents ranged from 10.8 (1986-1987) up to 15.2 (1998-1999). Despite the limited experience treating thyroid disease, it still made up an average of two thirds of the total operative endocrine experience in resi

Parathyroid Surgery Distribution

Figure 11.2 Distribution of thyroidectomies performed by residents (1993-1994). (Reproduced from Harness K, Organ CH Jr, Thompson NW. Operative experience of U.S. general surgery residents in thyroid and parathyroid disease. Surgery. 1995 Dec; 118(6):1065. Copyright 1995, with permission from Elsevier.)

Figure 11.2 Distribution of thyroidectomies performed by residents (1993-1994). (Reproduced from Harness K, Organ CH Jr, Thompson NW. Operative experience of U.S. general surgery residents in thyroid and parathyroid disease. Surgery. 1995 Dec; 118(6):1065. Copyright 1995, with permission from Elsevier.)

dency [5]. The average number of parathyroidectomies ranged from 4.1 to 5.1 per year, and even fewer adrenalectomies (0.98 per year) were performed [5,6].While an increasing trend was seen, this study questioned whether this relatively small volume of cases provided adequate exposure to the broad array of thyroid disorders that surgeons may encounter in an active clinical practice. Less common clinical entities such as large substernal goiters, invasive malignancies, large distorting neoplasms, locally recurrent tumors, and anaplastic or medullary thyroid cancer all add complexity and difficulty to thyroid operations and are unlikely to have been encountered to any great degree during residency training. It is probable that experience with the lymph node dissections often required for appropriate treatment of patients with thyroid cancer is equally limited, although no data, to our knowledge, are currently available.

Since residency remains the endpoint in training for most surgeons who perform thy-roidectomies and other endocrine procedures, it is important to consider how many operative procedures should be performed during residency in order for a trainee to be considered competent and qualified. The Residency Review

Committee (RRC) for Surgery in the USA defines the minimum number of operations required in training for each category of general surgery, and has established that only eight endocrine operations are required. The minimum for the "head and neck" category is 24, but this criterion can be fulfilled by operations such as neck exploration for trauma, carotid endarterectomy, superficial parotidectomy, as well as thyroid, parathyroid, and lymph node resections [5]. The endocrine requirements do not specify criteria for each specific endocrine gland (thyroid, parathyroid, adrenal or endocrine pancreas) or for specific disease processes (benign or malignant). Strictly from an accreditation point of view, the average general surgery resident in the USA easily meets the current caseload criteria for endocrine surgery training; however, when the Accreditation Council for Graduate Medical Education requirements were established, they did not take into consideration the range of pathology treated within surgical endocrinology.

Some residents receive appreciable experience in endocrine surgery during their residency. Harness et al. found that the maximum number of thyroid operations (either partial or complete thyroidectomies) performed by a single resident was 102 [5]. The maximum number of parathyroidectomies and adrenalec-tomies performed were 60 and 15, respectively [5,6]. These numbers are significantly above the average resident's experience, and indeed, some residents will perform more thyroid operations in their residency than many general surgeons will in their entire career [1,5,7]. This variability suggests that the level of skill, knowledge, and understanding of endocrine diseases to achieve the successful practice of endocrine surgery within a general surgery career can be acceptable for many residents, and even exceptional for some. Whereas minimal experience in residency coupled with an occasional thy-roidectomy in practice is not an optimal situation. Currently, evidence-derived recommendations for minimum training volume do not exist. Because of the large variations in exposure to endocrine operations among residency programs and general surgery practices, carefully controlled studies are needed to shed light on this controversial issue.

Some residency programs and residents have difficulty meeting the RRC minimum standards for training in endocrine surgery. Although the mean values from the Harness study could be influenced by case volume outliers, the modal values for thyroidectomy (8 to 10 cases per graduating resident) and parathyroidectomy (2 to 3 per graduating resident) continue to reflect a concerning paucity of exposure [5]. A limited residency case volume is likely indicative of a limited endocrine practice of the faculty members within such programs.

The majority of general surgery residency programs do not have specialist endocrine surgeons on their faculty. A study of the 268 general surgery residency programs in the USA in 1993-1994 discovered that only 70 programs (26%) had an endocrine surgeon (defined as a member of the American Association of Endocrine Surgeons) on staff [4]. This proved to be an important factor. Those programs with an endocrine surgeon had greater numbers of thyroidectomies, parathyroidectomies, and overall endocrine cases than those without one. In addition, residents from programs with an endocrine surgeon tended to score higher on the endocrine section of the qualifying examination of the American Board of Surgery in 1994, and this difference was statistically significant in 1995 [4].While the value of having endocrine surgeons teach the corresponding clinical workup, operative procedures, and post operative follow-up was statistically evident by standardized test results, whether the test results and case volume differences noted in this previous study were clinically relevant is debatable. The presence of an endocrine surgeon on the teaching faculty did not affect the paucity of residents' exposure to uncommon endocrine procedures, such as those involving the endocrine pancreas [4]. This is likely due to the lack of power to detect such a difference, as the overall number of these cases is low.

There are other probable advantages to having an endocrine surgeon on the teaching faculty that were not evaluated in the Harness study. These surgeons tend to operate on greater numbers of patients with endocrine disease, thereby increasing the depth and breadth of the resident's exposure. This not only provides additional training in the clinic and operating room, but it helps create an understanding of the complexity of cases that this discipline can entail. This understanding stems from the uncommon and challenging clinical endocrine scenarios that have a low incidence in the general population, but an increased incidence in the referral practice of the specialist faculty. Respect for the amount of experience and knowledge required to provide optimal patient care can be garnered from an endocrine surgeon - perhaps better than it can be from a nonreferral-based and nonspecialized surgeon. This view is supported by Cheadle et al., who demonstrated an increase in the volume and complexity of chief resident cases when specialty faculty from other areas of general surgery joined the department [8]. New faculty members specializing in surgical oncology, hepatobiliary, colorectal, and vascular surgery developed major referral practices that exposed residents to a wider, more challenging range of cases in their fields [8]. The greater volume and complexity of a surgical referral center may be accompanied by an increased multidisciplinary involvement of colleagues in radiology, nuclear medicine, pathology, and endocrinology and this also contributes to the residents' clinical exposure.

An Australian study of complications from total thyroidectomy demonstrated that appropriately trained general surgeons performed this operation with complication rates comparable to their endocrine surgeon counterparts, despite the significant difference in practice volume (146 versus 2-16 thyroidectomies per year) [9]. The general surgeons were former trainees in an endocrine surgery specialty unit during their residencies and at the time of their graduation were thought to be proficient in thyroid surgery. This study suggests that well-trained general surgeons who are proficient and safe in endocrine surgery when they complete their residency training can continue to be once they are in practice in the community.

Perhaps the most important influence an endocrine surgeon has in a general surgery training program is on the recruitment of future endocrine surgeons by exposing residents to the opportunities in the field. Endocrine surgeons may serve as mentors for medical students and residents who have an interest in this field of surgery or who will develop such an interest because of their mentorship. A survey of senior surgeons at regional and national surgical societies found that their "role models" were the number one influence on their choice of career specialty [10]. A separate survey found that two thirds of general surgery graduates chose the same career as their mentor [11]. With the declining number of medical students pursuing careers in surgery and the high attrition rates of those who begin general surgery programs [12], the general surgery profession and its specialties need more role models to encourage and support young surgeons [13,14].

General surgery residencies should provide adequate experience in thyroid surgery so that their graduates can perform uncomplicated thyroid operations with minimal morbidity [4,15,16]. With this solid baseline training, and by staying on top of emerging and changing treatment options and guidelines, these graduates can continue to safely and effectively treat most endocrine diseases that require surgery. Recognition of personal and institutional limitations will result in appropriate referrals to colleagues who have additional training and experience [15].

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